Inspection on 14/12/06 for Brookthorpe Hall Care Centre

This inspection was carried out on 14th December 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Brookthorpe Hall Care Centre 07/04/09

Brookthorpe Hall Care Centre 21/04/08

Brookthorpe Hall Care Centre 06/03/06

Brookthorpe Hall Care Centre 05/09/05

Brookthorpe Hall Care Centre 13/01/05

Brookthorpe Hall Care Centre 27/05/04

Similar services:

2 Perhaver Park

The Vicarage

Fairfields Country Rest Home

St George`s

5 Seafield Road

Credence House

Poldhu

Queensmount

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Brookthorpe Hall Care Centre Stroud Road Brookthorpe Glos GL4 0UN Lead Inspector Nick Jones Key Unannounced Inspection 14th December 2006 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Brookthorpe Hall Care Centre DS0000016392.V306036.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Brookthorpe Hall Care Centre DS0000016392.V306036.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Brookthorpe Hall Care Centre Address Stroud Road Brookthorpe Glos GL4 0UN Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01452 813240 01452 814394 Frampton Residential Homes Limited Mrs Michaela Brisland (nee Chandler) Care Home 32 Category(ies) of Learning disability (2), Old age, not falling registration, with number within any other category (30) of places Brookthorpe Hall Care Centre DS0000016392.V306036.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Two beds can be used for service users under the age of 65 years of age. That service users under 65 years of age must be over 50 years of age. 6th March 2006 Date of last inspection Brief Description of the Service: Brookthorpe Hall is a nineteenth century building that has been sensitively adapted for its stated purpose. It is registered to provide personal care for 30 older people, with an additional category for two people with a learning disability. This Care Home therefore does not provide nursing care. The home is very spacious and provides easy access with a staircase and shaft lift accessing all four floors. Communal lounges and a dining room are situated on the ground floor and residents’ private accommodation is located over three floors. The home uses contracted caterers offering a good degree of choice of meals for residents. The home has an activities co-ordinator and provides varied optional opportunities for social activity and interests. This home aims to meet the National Minimum Standards (NMS) for Older Persons and meets with requirements from other statutory agencies such as the Fire Department and Environmental Health Department. The home makes available copies of the Service User Guide and CSCI inspection reports to prospective residents. The monthly fees charged by the home range from £1351 to £2232. Brookthorpe Hall Care Centre DS0000016392.V306036.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The judgements contained in this report have been made from evidence gathered during the inspection, which included a visit to the service and takes into account the views and experiences of people using the service. This unannounced key inspection was carried out over two days on the 14th and 18th December 2006. The Registered Manager, Deputy Manager and the Activities Co-ordinator were on duty as were other members of the home team. Both of the proprietors were spoken with and provided particular information about staff training, resident’s finances and staff recruitment. Five staff were spoken with. Four residents and a relative were spoken with in detail, several others were asked their views on the food and how they spent their day. A District Nurse attending the home was also spoken with. Before the visit a pre-inspection questionnaire was returned, with several staff surveys, relative’s comment cards and resident surveys also being returned. A tour of the building including all communal areas was completed; some individual bedrooms were also viewed. Pre admission assessments were read along with a sample of residents’ care plans and other related care documentation. Chosen areas of the medication system were inspected, including related records. Lunchtime was observed and residents’ views on the food sought. A sample of records of staff recruitment and staff training were viewed. The general management of the home was inspected which included systems such as staff supervision and quality assurance. Health and safety records were also viewed. What the service does well: The service has proprietors, managers and staff who are committed to providing residents with a high quality of care. Residents commented that “It’s really, really lovely here”, “I like talking to the staff and other residents here” and that ”I like my room and my relatives visit whenever they want”. Feedback from outside professionals and respite residents and their relatives was very positive about the professionalism and commitment of staff. Residents are supported to make choices about where and how they spend their time. They stated that they feel able to express ideas and concerns to staff and the management team. Brookthorpe Hall Care Centre DS0000016392.V306036.R01.S.doc Version 5.2 Page 6 Care plans, health records, and medication administration are well organised and provide relevant information to assist staff to meet the needs of residents. The activities co-ordinator consults with residents to provide a varied range of activities both inside of and out of the home. A good standard of home-cooked food is provided, with consideration to individual likes and dislikes. A clean, homely and comfortable environment is provided. Sound recruitment and selection procedures, in the main, help to protect service users. Staff are trained and supervised well. The management team provide good support, leadership and direction to the staff team. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Brookthorpe Hall Care Centre DS0000016392.V306036.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Brookthorpe Hall Care Centre DS0000016392.V306036.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The assessment procedures used by the home largely ensure residents’ needs are assessed and met. Intermediate care is not provided at the home. EVIDENCE: The documentation of five residents was viewed which all included details of assessments undertaken before the resident moved to the home. These assessments have been used to inform the devising of care plans. The assessment completed for one resident contained some details ascertained before they moved, with others gained from the resident and a relative when they arrived at the home for a respite stay. The manager stated they were not able to complete the assessment before the respite stay due the distance the resident lived from the home. Discussions took place about being able to complete as much of the assessment as possible by phone to the resident, their relative and other health professionals involved in the person’s care. Brookthorpe Hall Care Centre DS0000016392.V306036.R01.S.doc Version 5.2 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 The care records were, on the whole, detailed, well written and reviewed on a regular basis to ensure residents’ needs and wishes were met. Healthcare professionals support the residents and appropriate records were made of their visits, which ensure health is maintained. Staff support residents in a manner that maintains their privacy and dignity. The system for medication storage and administration are good with clear and comprehensive arrangements in place to ensure residents’ medication needs are met safely. EVIDENCE: The personal files of residents were viewed, four in more detail. They included written care plans that were well written and described a range of health and support needs. They were reviewed on a monthly basis. They included plans for nighttime support. One care plan for a new respite resident was not completed in as much detail as the other care plans viewed. The manager stated the plan would be developed in more detail during further respite stays that the resident and their relatives were happy to consider. Brookthorpe Hall Care Centre DS0000016392.V306036.R01.S.doc Version 5.2 Page 10 The care documentation also contained other assessments such as oral assessments, moving and handling assessments and assessments relating to potential pressure ulcers. Risk assessment documents described issues such as the need to use a hoist, risks of isolation and the need for a radiator cover in a bedroom. Records showed that access to all health services and outside agencies is ensured, when and wherever needed. There was evidence that a residents’ GP was involved in regular reviews of resident’s health and medication. Regular chiropody appointments were available to residents. A District Nurse who visits the home twice a week thought that the home offered a good standard of care. She was confident that staff followed the instructions left for them. Files viewed and discussions with staff showed the Continence Nurse Advisor was a regular link to the home. The medication system was inspected and all were being stored appropriately and were organised with only the stock required at that the time being stored. Records were kept correctly with no gaps in administration. One resident was assessed to be able to self-administer their medication. The manager described how the home had discussed any risks with the resident and checks they undertake to ensure prescribed medication was being taken. There was not a written, up to date and reviewed risk assessment in place for this resident. A selection of staff training files were inspected and certificates were seen in accredited training for medication administration. All of the residents spoken to confirmed that staff are respectful, kind and attentive to their needs, and that they are thoroughly mindful of their privacy. Staff were observed going about their duties and interacting with residents in a friendly, relaxed and respectful way. A visiting relative stated they were very happy with the care being given to their relative and would recommend the home to anyone who needed residential care. Brookthorpe Hall Care Centre DS0000016392.V306036.R01.S.doc Version 5.2 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents have a varied activities programme, which meets their individual lifestyle needs. Residents are supported to maintain links with family, friends and the local community. Residents are supported to lead independent lives for as long as they can and to make their own choices. The meals in the home are good and aim to meet a wide variation in taste and dietary need. EVIDENCE: The home employs an activities co-ordinator who works at the home four days a week. Discussions take place with individual residents and in occasional group meetings to gain their views as to preferred activities. Sessions such as Brookthorpe Hall Care Centre DS0000016392.V306036.R01.S.doc Version 5.2 Page 12 bingo, quizzes, music and movement, cards and games are provided in the home. Various entertainers visit to perform at the home and occasional day trips are provided. A resident and a relative talked about enjoying a canal boat trip. Residents are also supported to go for walks and visits to local pubs. One resident chooses to go twice a week to a local community day centre. Other residents have been offered this but declined. A local vicar visits the home every two weeks. Christmas decorations were being put up during the inspection. Residents are free to spend their time how and where they wish. All of those spoken to confirmed that staff are fully respectful of their personal choices and wishes. A visiting relative stated they were always able to visit their relative and came most days to visit. Residents are fully supported to retain their independence in so far as personal abilities will permit, and this includes handling their own affairs and finances. Residents are evidently able to exercise choices in their own rooms, with the introduction of their own items in order to personalise them. Residents are offered a choice of two meals at lunch and tea with alternatives offered to a resident with particular preferences being available. The cook was aware of residents with special diet requirements such as a soft diet or a diabetic diet. Menus viewed and food seen showed residents receive a varied and nutritious diet. There is a rolling three-week menu that is revised for spring, summer and winter choices. A record of food served to the residents is maintained. Service of the lunchtime meal was observed, which was in the lounges on one day due to the dining room carpet having been cleaned. The meal was calm and unhurried despite having to arrange the lounges into a temporary dining area. Staff were providing assistance where needed. Some residents chose to eat in their rooms and staff provided assistance where needed. Residents said that the food is ‘very good’, ‘great’ and ‘we get choices’. Brookthorpe Hall Care Centre DS0000016392.V306036.R01.S.doc Version 5.2 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is a satisfactory complaints system, with evidence that residents feel that any concerns they may have are listened to and acted upon. The home’s Adult Protection policies help to provide a safe environment for the residents. EVIDENCE: There is a clear complaints procedure that is easily accessible to all in the home. All residents spoken to confirmed that staff were very approachable, and were always ready to listen to any views they may have. The complaints procedure was on the office notice board and the main notice board of the home. Visitors and most residents would be able to see this. The home has a written policy on abuse, and has a Whistleblowing procedure for staff to follow if they had any concerns. Brookthorpe Hall Care Centre DS0000016392.V306036.R01.S.doc Version 5.2 Page 14 Most of the staff team have attended recent training in the protection of vulnerable adults. The rest of the staff were booked to attend this training early in 2007. A relative stated all staff were approachable and would listen to the concerns of a resident and /or relative. Comment cards returned by relatives stated they were aware of the home’s complaints procedure. Safe storage is available should any resident wish to place valuables with the home for safekeeping. Brookthorpe Hall Care Centre DS0000016392.V306036.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides safe, well-maintained accommodation for residents to live in. A homely and clean environment is provided for residents with appropriate infection control measures in place. EVIDENCE: Communal areas seen were found to be bright, clean, comfortable and homely where the decoration and furnishings were of a high standard. There is an ongoing programme of refurbishment and maintenance to ensure that the quality of the environment is maintained at a good standard. Window frames in one of the lounges were being replaced and decorators were touching up various areas of the home at the time of the inspection. A new stair lift has been installed which allows residents to access the mezzanine floor. The home has a maintenance book where staff can enter items that require attention. It Brookthorpe Hall Care Centre DS0000016392.V306036.R01.S.doc Version 5.2 Page 16 was well organised and showed the home is responsive to all maintenance issues. Residents stated they enjoyed being able to sit outside in the different areas of garden during the warm weather. The home was found to be clean, hygienic and free from odours. The dining room carpet was being cleaned on the first day of the inspection. The home is cleaned to a good standard, with laundry and clinical waste handled appropriately for the prevention of cross infection. Gloves and aprons are provided for staff. The laundry was clean and well organised. Brookthorpe Hall Care Centre DS0000016392.V306036.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staffing numbers and skill mix are adequate to meet the needs of the residents currently living in the home. Appropriate recruitment and selection procedures help, in the main, to protect residents. Support is provided by a skilled and appropriately trained staff team, helping to ensure that residents’ needs are consistently met. EVIDENCE: Several staff were spoken with fulfilling a variety of roles within the home. There are a minimum of three care staff working during the day with two waking night staff working each night. On the days of the inspection there was a senior carer and two care staff, three kitchen staff, two domestics and a part-time laundry assistant. Discussions with staff and residents, viewing returned surveys and comment cards, and viewing staff duty rotas showed there are sufficient numbers of staff working at the home. The home is an accredited ‘Ed-excel’ training centre and therefore there is a great enthusiasm for good staff training. The accreditation rating has just been assessed for a third time in succession as an ‘A’ rating. There is a large–sized training room in the basement where staff are able to access several Brookthorpe Hall Care Centre DS0000016392.V306036.R01.S.doc Version 5.2 Page 18 computers and work on their NVQs. The room is used for training sessions and courses. The majority of the staff either hold an NVQ level 2 or 3 Award or are in the process of achieving this. All new care staff contracts stipulate part of their duties will be to undertake NVQ training. Examples of NVQ records were viewed which were detailed and well organised. Discussions with staff confirmed they are well supported to undertake and complete their NVQ Awards. The management team discussed the intention to recruit an additional senior member of staff to free up some time for the manager and deputy manager to undertake NVQ assessments at other Registered Care Homes. The recruitment files of three staff recruited during 2006 were viewed. They contained all the required checks and records that included a PoVA First and CRB check. The proprietors were not certain whether the catering agency that provides kitchen staff for the home routinely undertake CRB checks for their staff. It was recommended that clarification should be sought from the agency to ensure these checks are undertaken. Training records and discussions with staff showed they are provided with structured inductions and on-going training. The home had been using the TOPSS induction format that has changed more recently to the Skills for Care format. Staff are provided with a range of mandatory training that includes safe handling of medicines, first aid, moving and handling, infection control, fire safety at work, adult protection and food hygiene. Brookthorpe Hall Care Centre DS0000016392.V306036.R01.S.doc Version 5.2 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38 Quality in this outcome area is good though one aspect of provision was considered adequate. This judgement has been made using available evidence including a visit to this service. The home is run by an experienced Registered Manager who has worked at the home for many years. The home seeks to obtain the views of residents and relatives about their quality of care and life. The systems for recording and collating this information require improvement. Systems are in place to ensure residents’ financial interests are safeguarded. Management systems are in place, which are designed to safeguard the residents. Brookthorpe Hall Care Centre DS0000016392.V306036.R01.S.doc Version 5.2 Page 20 EVIDENCE: The Registered Manager is an experienced manager who demonstrated her commitment and support to residents and staff. She has worked at the home for many years. She holds all the required qualifications in management and care practice and is also a NVQ Assessor. The Deputy Manager in turn supports her along with senior care staff. Residents commented that they find both very approachable, including the one relative spoken to during this inspection. Similar views were expressed about the proprietors. Discussions with the proprietors, staff and residents showed the home seeks the views of residents in their care and quality of life. There views are sought on matters such as activities, outings and the food menu. The manager was able to produce some copies of ‘client feedback’ forms that had been filled in by residents, particularly respite residents. They were all complimentary as to the standards of care provided by staff. The manager and cook described organising a meeting to allow residents to express their views and preferences about food menus. There was no record of this meeting or the views expressed. Discussions with residents confirmed the meeting had taken place. A discussion took place with the manager and proprietor as to how regular ‘client feedback’ forms could be provided to all residents and results summarised in writing. Meetings or discussions with residents should also be recorded to provide a record of consultation and could form a basis for the home to produce and review an annual plan. The home is an ‘Edexcel’ training centre and this status involves the use of quality assurance systems in relation to training provision. The Registered Proprietor explained that the home does not take any responsibility for the safe keeping of personal monies, although each bedroom is provided with a lockable drawer. All monies are dealt with through a Power of Attorney arrangement or the resident has their own informal agreement with their family. Staff records viewed showed they are provided with regular supervision sessions and annual appraisals. Staff stated they could talk to their supervisor or any of the senior staff if they wished. The Proprietor provided on-going supervision to the management team. Team meetings were seen to take place approximately every two months with minutes of the meeting being taken. There was evidence that health and safety issues are addressed in this home, with written policies, procedures and risk assessments, provision of necessary equipment and staff training. All necessary maintenance of equipment is undertaken in a timely fashion. This included the servicing of hoists and the lifts. Fire safety equipment and Brookthorpe Hall Care Centre DS0000016392.V306036.R01.S.doc Version 5.2 Page 21 systems are regularly tested and serviced. Records showed fire drills were undertaken with a fire safety risk assessment identifying that the home has a ‘stay put’ policy for residents in the event of a fire. Brookthorpe Hall Care Centre DS0000016392.V306036.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 3 X 3 Brookthorpe Hall Care Centre DS0000016392.V306036.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP3 Regulation 14(1)(a&b ) Requirement The Registered Manager must not offer accommodation to a service user unless the needs of that person have been fully assessed by a person competent to do so. Timescale of 26/05/06 not met. Timescale for action 31/03/07 2. OP33 24(1)(a&b ) 30/04/07 The Registered Manager must devise a system that helps not only ascertain views from service users on the home’s services, but that helps the home identify where improvements to care and services can be made and which is able to measure any action taken. Timescale of 1/07/06 not met. Recruitment of all staff including kitchen staff must include confirmation of a CRB clearance. Risk assessments must be written and regularly reviewed for any resident who takes responsibility for their own medication. 31/03/07 30/04/07 3. 4. OP29 OP9 19 13(4)(c) Brookthorpe Hall Care Centre DS0000016392.V306036.R01.S.doc Version 5.2 Page 24 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP7 Good Practice Recommendations Care plans for respite residents should be completed in further detail for all respite residents Brookthorpe Hall Care Centre DS0000016392.V306036.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Gloucester Office Unit 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester, GL3 4AB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Brookthorpe Hall Care Centre DS0000016392.V306036.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!